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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1860 E.HAZELTON AVENUE-STOCKTON CA 95206-(209)468-3420 NON-REFUNDABLE PERMIT CALL(20p)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DAT SUED JOB ADDRESS `1 �_ _�Q�JS� ./ O r Cn'YIZIP - An 140, `"t 5!�_ CROSS STIR APN ��V7 v v1� I� PARCEL SIZE Cpa OWNER NAME � �` �� j �� ?-LM'�'tfl ,t ma �ttrx�. PHONE p 9 OWNER ADDRESS -� kJ IG,L' (tNk'.1 L-1% -ITY�7S'rATZ)IP� _-j, _cr{,j' Tc•�} f5�� CONTRACTOR— !(�5 --_-1g_f.i—_._.-_..._...._._..-PHONE CONTRACTOR ADDRESS —'A CITYISTATEIZIP�CA�ILOI'��y� I S3 SLS LICENSE LIZ-42 CILIC-36 OTHER___A___i NUMBERICA76ff. �EXPIRATION DATE -0 WATER TABLE DEPTH: Q_� ft GEOGRAPHICAL INFORMATION: COOrdl S X Y I) FERC TEST # _ BUILDING PERNAIT#� LAND USE APPLICATION# TYPE OF WORK: EW INSTALLATION REPAIR/ADDITION 1'.i ENGINEER DESIGNED(ALTERNATIVE .., REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM li DESTRUCTION INSTALLATION WILL SERVE: EsmENCE _ :l COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF$EDROdMS: - NUMBER OF EMPLOYEES: FX SEPTIC TANK TYPE/MFG CAPACITY � gal #OF COMPARTMENTS , 0 GREASE TRAP I-YPE/MFG _ CAPACIT'Y gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL to.' it FOUNDATION (o i ft PROPERTY LINE ❑ LIFT STATION SIZE TYPE OF PUMP 13 PKGTX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) tr LEACH LINES !i LEACHING CHAMBERS #of LINES_LL_ LENGI H OF LINES�V ft DISTANCE TO NEAREST WELL �,Jit FOUNDATION ( ft PROPERTY LINE,,_. It ❑ FILTER BED WIDTH it LENGTH it DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINE It ❑ MOUNDED WIDTH ft LENGTH it DEPTH ft DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE it O SUMPS WIDTH it LENGTH _ ft DEATH ft DISTANCE TO NEAREST WELL ft FOUNDATION ^'�. It PROPERTY LINE it O DISPOSAL PONDS WIDTH ft LENGTH_ ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE it SEEPAGE PITS NUMBER4 WIDTH - I f % DEPTH !Y�r it DISTANCE TO NEAREST K'tLL 1 it FOUNDATION (00,1 it PROPERTY LINE .5 it I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. MINIMUM48 H VANCE NOTMEREQUIRED FOR SIGNED TITLEDATE 1 I N -— H E,. AR TM EN— SE ~N Y Application Accepted B ---_.._ Date- -- Area Employee ID#� Final Inspection By "—.... Date i SPECIAL PERMIT-Approved by Character of SoI Soil to�eeptthh off 3 Ft: _ P/i-t/ ump Soil Character: �p COMMENTS L� 9 . 1 -- -- -- �q ............... __ .._._.--_ ____-_....._.__ __.__..___._.__.__._.._.__._.....-_ ____.._ �s-- PE SC Received Amount— Permit/ Invoice# _ Permit ID# Code INFO B Cash Remitted Seryice Re uest# — 4201 ONSITE WASTEWATER T`RTMNT SYSTEM PERMIT 4114118